But since the devastating September 11, 2001, disasters in which more than 3000 people perished and last falls anthrax attacks that killed five people, the 334-bed Arlington hospital has modified its disaster preparations to focus on ensuring that inpatients and staff members are safe and that its facility is secure.

"Now, it is not just treating victims of a bus or plane crash that we have to worry about," Anderson said. "The factor of terrorism causes us to think differently about the patients who are walking up to our facility. We now look at things differently with our disaster drills than we ever have in the past."

When terrorists hijacked American Airlines Flight 77 and crashed it into the Pentagon, killing 189 people last year, over 40 injured Pentagon workers were transported to Virginia Hospital CenterArlington for treatment, according to Anderson.

"It was a knee-jerk reaction for many of our staff to immediately start coming in to work that day," he said. "But now, we dont advise staff to come in immediately after a disaster. We dont want to bring our staff into what could be a hazardous situation. We dont want more victims."

Anderson said his hospital has developed a "lockdown" procedure to secure the facility from a terrorist attack and to ensure that a patient with a contagious, deadly disease, such as smallpox, does not infect other patients or staff members.

Part of the hospitals revised emergency preparedness plan, Anderson said, includes setting up a triage area outside where a health care professional can decide whether to let the patient enter the main facility.

The hospital has added more health care workers to its training program for responding to bioterrorism, Anderson said, noting that much of that training includes teaching staff the proper way to wear special protective biohazard suits.

"We want to make sure nothing happens to our staff when they are wearing the biohazard suits," Anderson said, noting that the suits are sometimes bulky and the facemasks breathing apparatus may affect a persons natural breathing pattern.

To be better prepared for the next emergency, Anderson said, the pharmacy department now maintains a special "disaster cart" with drug products and antidotes, such as pralidoxime chloride, to treat up to 30 victims of chemical warfare or a bioterrorist attack.

Perhaps a sign that many facilities have adopted a plan similar to Andersons, Wyeth Pharmaceuticals announced in August that it has a limited supply of pralidoxime chloride and will supply the agent only to hospitals, health clinics, and frontline health care providers on an emergency basis.

Virginia Hospital CenterArlington, Anderson said, has also increased its supplies of antimicrobials and other antiinfectives, including ciprofloxacin, a drug prescribed to many of the people who were potentially exposed last fall to Bacillus anthracis.

In the event of a public health emergency or a large-scale disaster in which a greater-than-expected amount of pharmaceuticals is needed, he said, the hospital plans to rely on its contracted wholesalers to supply more products.

If necessary, Anderson added, state and local emergency management agencies could help his pharmacy access the National Pharmaceutical Stockpile, a federal repository of antiinfectives, chemical antidotes, antitoxins, life-support medications, i.v. administration and airway maintenance supplies, surgical items, and other medical supplies.

Jay Barbaccia, pharmacy director for Washington Hospital Center in Washington, D.C., said that, when the September 11 disaster and anthrax exposures occurred locally last year, most D.C.-area hospitals were "left in the dark" about how to access the federal stockpile of drugs and supplies.

"At first, it was very difficult to get the government to give us any information" about the National Pharmaceutical Stockpile, he said. "But since last year, there has been a greater dialogue and better cooperation from the federal government that didnt take place before."

Many of the victims from the Pentagon were transported to Washington Hospital Center, the designated hospital to which local emergency-response teams transport burn victims, Barbaccia said.

The pharmacys contracted wholesalers, he added, were able to quickly supply extra containers of silver sulfadiazine cream for the burn patients.

Since last year, Barbaccia said, his pharmacy has taken measures to ensure it stocks a larger inventory of some drug products, such as antiinfectives and antidotes.

"We plan on having enough materials on hand to carry us through during any disaster until we can get access to the National Pharmaceutical Stockpile," he said. "We must be self-sufficient in the meantime."

According to the Centers for Disease Control and Prevention (CDC), the stockpile is not a first-response tool. CDC can ship a 50-ton stockpile of antiinfectives, chemical antidotes, and other medical supplies to most U.S. locations within 12 hours of a federal decision to release the supplies, according to an agency spokeswoman. But local hospitals and state or city governments, she said, should be prepared to coordinate the treatment of patients until federal supplies arrive.

Washington Hospital Center, Barbaccia said, has also implemented a bioterrorism alert system, known as code purple, that alerts pharmacists and other health care workers to have antiinfectives and biohazard protective equipment ready to use. The hospitals code orange signals staff about other types of disasters.

Barbaccia said his hospital has revised its scheduling procedures to ensure the availability of health care professionals and support staff in the event a disaster occurs at night or on a weekend.

Lorna Lagarde, pharmacy chief of the DiLorenzo Tricare Health Clinic at the Pentagon, said she has revised her staffing schedule to ensure that a pharmacist and technician are always available.

Lagarde, who was at the Pentagon when the airliner hit, worked 28 hours nonstop outdoors at a makeshift pharmacy under large umbrellas while emergency rescue workers, physicians, and nurses treated patients near the burning building.

One important lesson she learned, Lagarde said, was how vital it is, in an emergency situation to have a sign that identifies where the pharmacy is located.

"No one could find us," she said. "I only had a small piece of paper taped to the front [of the makeshift pharmacy] that acknowledged who we were. We had people leaving boxes of drugs all over the place. It was chaos."

Lagarde said the Pentagon has provided her with a pharmacy banner that pharmacists can use during another disaster to identify their mobile site.

Specialists with the Office of Homeland Security, Lagarde said, helped the Pentagon revise its emergency preparedness plan. The Pentagons pharmacy now stocks special emergency kits that contain potassium iodide, pralidoxime chloride, and other antidotes. In addition, the pharmacy increased its supply of antiinfectives, silver sulfadiazine cream, and other emergency supplies.

Karol Wollenburg, vice president and apothecary-in-chief for New York Presbyterian Hospital in Manhattan, said her pharmacy has always stocked a supply of critical drugs used in emergency situations. But since last year, she said, the hospital has increased its stock of those drugs, and it conducts more regular inventories to ensure an adequate supply.

Many of the victims who were critically burned when the World Trade Center was attacked last year were transported to New York Presbyterian Hospitals burn treatment center on the Weill Cornell Medical College campus.

Wollenburg had to ensure that the burn treatment center had an ample supply of silver sulfadiazine cream. But telephone service had been interrupted throughout the day, creating an obstacle for the pharmacy in obtaining the product.

"We had a little bit of trouble in trying to get orders to the wholesaler," she said, adding that the pharmacy did obtain a sufficient supply of the burn cream.

Since then, Wollenburg said, the hospitals pharmacy has established a special drug list for its wholesalers to keep on file so that, if telephone communication is lost during a disaster, they can deploy an emergency shipment of the listed products directly to the hospital without an order. The list, she said, helps the wholesalers know which drugs are essential during a disaster and must be kept in inventory.

She has also asked her wholesalers to develop written protocols that include the criteria to be used when deciding which hospitals would receive supplies during a large-scale disaster in a concentrated area. Wollenburgs hospital is part of the New York Presbyterian Healthcare System, a network of 47 acute care hospitals and nursing homes in New York, New Jersey, and Connecticut.

The health system has established a special Web site for its hospitals to communicate and share information about drug and medical supplies, bed capacity, and staff availability.

Carol Jean Guittari, pharmacy director for St. Vincents Hospital in Manhattan, said that hospitals, when designing emergency preparedness plans, should not overstock pharmaceuticals that are in short supply, a practice that could exacerbate the ongoing problem of drug product shortages. But, she added, it is necessary to keep adequate supplies of drug products used in emergency situations.

Officials from the U.S. Public Health Service, Guittari said, contacted her shortly after injured victims began arriving at her hospital on September 11, 2001.

"I had the benefit of seeing how the National Pharmaceutical Stockpile works," she said. "It did take a few hours before we got the push package, so we had to call around and borrow a few things from other hospitals."

One problem her pharmacy discovered in relying on products from other hospitals, Guittari said, was that the silver sulfadiazine cream supplied by a neighboring hospital came in large tub containersthe unused contents had to be discarded as waste.

"We know now that, even though a hospital might say they can give us things, it may not always be desirable for that situation," she said. "We keep smaller packages of [the cream] on hand now for our patients, and we have asked our wholesalers to keep the small package size in stock."

To be more efficient in deciding which types of emergency drugs to stock, Guittari has established a list of drug products based on the types of patients and potential injuries to be treated during a disaster.

"Hopefully, we have learned enough to deal with the next disaster efficiently," she said. "I think we all understand now that an emergency preparedness manual is not something to be pushed aside."

At Cooper Health System in Camden, New Jersey, "everyone has learned a lot about how potentially unprepared we all are for a disaster," said Pharmacy Director Jackie Sutton.

Sutton helped dispense antiinfectives to hundreds of postal workers and counseled them about the possible adverse effects of ciprofloxacin, doxycycline, and amoxicillin after the New Jersey Health Department announced on October 31, 2001, a suspected case of cutaneous anthrax in a postal employee who worked in Bellmawr.

Sutton said area hospitals, local emergency-management service agencies, and drug wholesalers have been meeting monthly since last fall to improve emergency preparedness in New Jersey and neighboring communities in Delaware and Pennsylvania.

"We have always had disaster drills at our hospital, but the scope of things has changed now," she said.

Sutton said hospital pharmacies should not stockpile drugs, not even to prepare for an emergency.

"That is the job of the wholesalers," she said. "They are the ones responsible to get us the drugs we need if there is an emergency. A pharmacys job is to be ready to receive potential additional supplies."

Pharmacists can prepare for disasters by having written protocols in place, she added.

"They should know in advance which medications are going to be neededdown to antidote dosing," she said. "It needs to be a very systematic approach."

Lessons Learned From Fall 2001 Disasters

Discourage staff members from entering the hospital unless their assistance is needed,

Stock a mobile cart with drug products and antidotes specific for treating victims of chemical warfare or a bioterrorist attack,

Maintain an inventory sufficient to last until supplies from the National Pharmaceutical Stockpile arrive, which could be more than 12 hours after the actual disaster occurs, but do not overstock the pharmacy,

Establish a special system alerting staff members of bioterrorist events,

Revise work schedules to ensure adequate staffing during a disaster occuring at night or on a weekend,

Have a banner that identifies the pharmacy if it has been relocated,

Work with wholesalers to establish a list of drugs that should be automatically delivered if telephones are out of service during an emergency, Do not overstock pharmaceuticals in short supply,

Expect that, when relying on supplies from other facilities, the package sizes may be different than what the staff is used to handling,

Decide which emergency drug products to stock by identifying the potential types of patients and injuries caused by a disaster, and

Prepare drug administration protocols, including dosages, for pharmaceuticals likely to be used.

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ASHP is the national professional organization whose more than 40,000 members include pharmacists, student pharmacists, and pharmacy technicians who serve as patient care providers on healthcare teams in acute and ambulatory settings.